COVID Long haulers

Darren’s story began in March 2020 when he arrived home from a long day of work as a hospital physical therapist, so exhausted that he fell into bed. He awoke the next morning with fever, shortness of breath, and pain. Recognizing these as COVID-19 symptoms, he isolated himself for 10 days before returning to work. For the next six months, Darren worked at the hospital with lingering fatigue and shortness of breath before finally embarking on a graded exercise program to increase his activity levels. But instead of getting stronger, Darren struggled to walk on his work commute and arrived sweating, short of breath, dizzy, and pale. Then simple activities like showering, walking from the bed to a sofa and even watching tv or reading left him exhausted.

Heather-Elizabeth is a 36-year old corporate trainer who started having a fever and feeling fatigued in April, 2020. Her fever rose to 103F and she developed gastrointestinal issues over  the next several weeks. Then she began to have trouble breathing and her blood oxygen levels dropped dangerously low. When advanced COVID-induced pneumonia showed up on X-ray, Heather-Elizabeth was admitted to the hospital and was placed in a medically induced coma on a ventilator for a month. In the process, blood clots formed in her leg and she developed left-sided body weakness with walking difficulties. Now over a year later, she still has a chronic lung condition and experiences chronic pain and mobility issues.  She has been diagnosed with type 2 diabetes with visual changes requiring insulin injections several times per day. While she once had an excellent memory, she now posts sticky note reminders everywhere to accommodate for brain fog.

April from Boise, Idaho was young and healthy and had been vaccinated for COVID-19 in January, 2021, but in July she was diagnosed with coronavirus. She was relieved that the course of illness was short, but as time went on she became increasingly fatigued and was unable to do even simple housekeeping tasks without sweating, and her pulse raced to 160 beats per minute. Then muscle and joint pain and dehydration began. The more active she was, the worse she felt the following day.

Darren, Heather-Elizabeth and April’s real-life stories are a sampling of the experiences of the growing number of COVID survivors. These “long haulers” are no longer contagious and test negative for COVID, but experience persisting function-limiting symptoms, uncertainty, and stress.

Studies show that more than one-half of unvaccinated COVID survivors and almost one-fifth of those few who have had vaccine break through experience one or more of a broad array of persisting physical and psychological symptoms, regardless of the severity of their initial illness. Many can only return to work part-time and some cannot work at all. (No data is available yet for the Omicron or future variants-stay tuned, I am following this!) The good news is that physical therapists have the expertise and tools to help guide long haulers along the road to recovery. Furthermore, exercise practitioners who are well-versed in the challenges long haulers face can offer help and hope for medically stable “graduates” of these programs who have lingering symptoms. Collaboration between therapists and community exercise providers can enhance a smooth transition for COVID long haulers from a rehab setting to community-based exercise venues. Community exercise providers need to be aware of the special considerations impacting this population as they work with them in personal training and group situations, to avoid triggering acute symptoms, set backs and relapse.

Please join me and Mary Wykle at the ATRI National Aquatic Therapy Conference in Chicago on April 9, 2022 as we share important information about the transition to safe and effective post-rehab long COVID interventions. Our presentation will highlight the gentle aquatic body mind practice of Ai Chi as a tool for addressing many of the most common persisting sequelae facing individuals with Long COVID.

https://www.atri.org/1020-covid-long-haulers.html

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Always something new…

Ai Chi Day 2021 is nearly upon us, and it promises many valuable presentations to expand knowledge of this practice and to spark ideas for new applications. Since Jun Konno introduced Ai Chi to the world over 2 decades ago aquatic specialists and therapists have successfully shared it with clients with many different issues and in a wide variety of settings. When the 2011 tsunami in Japan left many fearful of water, Jun developed new Ai Chi steps to reestablish comfort in the water. When an aquatic expert in the Netherlands could not find warm water pools where she could share Ai Chi, she developed a faster version that brought many of the same result through a different approach. A pediatric therapist found ways to use Ai Chi to help children with neurological deficits. Other practitioners have brought Ai Chi to wounded warriors suffering from PTSD.

Jun Konno’s gift of Ai Chi has proven to be a very useful tool that can be adapted to many situations, if we look mindfully at the possibilities and do not get caught up in performing it in one particular way. Jun often shared the Japanese proverbial saying: “Willow will not break under weight of snow.” The strong branches of trees can support the weight of snow in winter, but if too much snow accumulates, the branches will break. However, the willow tree does not need to bear as much weight. Its flexible branches are able to bend so that snow falls off, yet they are strong enough to spring back in shape.

Those who have been vaccinated against COVID-19 also seem to be protected against the new variants of coronavirus, (at least for now). However the variants are more aggressive and spread more easily than the original virus, making those who are unvaccinated at a higher risk of contracting it. Even a mild case can lead to long lasting, often debilitating symptoms~ now recorded at a rate of one out of every three who have tested positive for COVID. Ai Chi holds the possibility of addressing many of the most common COVID symptoms, however mindful adaptations are needed to avoid relapses. Both the CDC and the APTA have developed guidelines for assessment and outcome measures for post-COVID syndrome for healthcare professionals, including evidence based tools for fatigue, breathlessness, exercise capacity, balance, pain, functional mobility, cognition and anxiety. The results of these measures will shape the Ai Chi practice for each individual. And a prudent model will be needed for safe and effective general community group applications for extended help once therapy services are exhausted. Once again, however it turns out is how it was meant to be.

Please register at the following link to join ATRI for a very special online Ai Chi Day on Sunday, July 25, in celebration of Jun Konno and Ai Chi:
https://ruth-sova-103927.square.site/product/ai-chi-day-2021/452?cs=true&cst=custom

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More or less

As a physical therapist, I have found that many clients assume that faster recovery is dependent on longer therapy sessions or more vigorous exercise. This is in fact a myth. The truth is that while there are times when the best results come by pushing limits, there are also times when pacing is the key to success. In Scandinavia this middle ground is referred to as “lagom,” not too much, not too little. With attention to known information about disease processes, health professionals are tasked to listen to and observe their patients to determine that “sweet spot” of lagom for best outcomes.

Our world is now consumed by a novel virus that we are still learning about. We do not have a complete picture of the disease processes involved, but our understanding of it is emerging. Thankfully, an array of relatively quickly developed vaccines have been successful in curtailing the spread and severity of COVID-19, but not before many had contracted it. While more than we ever thought possible have succumbed to it, it is estimated that millions of people worldwide live with the aftermath, experiencing a wide range of persistent mild to debilitating symptoms, even after just a light case of the virus. Long haulers have turned to exercise to combat physical deconditioning and fatigue, with inconsistent responses. An editorial in the May 2021 Journal of Orthopaedic & Sports Physical Therapy was co-authored by researchers and by both those who have experienced long COVID and those with prolonged post-viral symptoms from another multi-system virus, myalgic encephalomyelitis/chronic fatigue syndrome. The article brings home the message of “lagom” to avoid relapses, which may take hours or even days to emerge. Their message is simple:

STOP trying to push your limits. Overexertion may be detrimental to your recovery.
REST is your most important management strategy. Do not wait until you feel symptoms to rest.
PACE your daily physical and cognitive activities. This is a safe approach to navigate triggers of symptoms.

How do you find that balance of “not too much, not too little?” The Borg Scale of Perceived Exertion is a good tool to find your personal pace (see March 15, 2017 Ai Chi Plus blog post, “Stretch your limits”). Start off by working or doing daily activities at a “fairly light” level (green range), even if it seems too easy. As your endurance improves you will find that what was “fairly light” initially is now very light and you will be able to do a bit more without ill effect. The Borg scale can be applied to everything from length of time out of bed, to walking distance, to exercise regimes~ even to doing Ai Chi steps that challenge core strength, balance, breath, mobility and reduce stress. Pace yourself to find that moving target of lagom.

If you are patient and pace yourself, you will get there!

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Getting our hands around Post-COVID-19 syndrome

Polio was once a looming threat in America, with outbreaks in the early 1950’s causing over 15,000 cases of paralysis each year prior to the introduction of the polio vaccine. The wide-scale vaccination process brought cases down to less than 100 cases in the 1960’s. In the 1970’s there were less than 10 cases, with the last reported case in the United States being in 1979. The most devastating symptom of polio is profound muscle weakness, with up to 10% succumbing to it, due to respiratory muscle involvement. Up to 40% of those who had recovered from polio had an unpleasant surprise 15-40 years after their original onset when they experienced the sudden return of muscle weakness, muscle and mental fatigue and joint pain, now called “Post-polio syndrome.” Thankfully this state is not contagious, nor is it considered life threatening, but it certainly can lead to profound disability. I remember my first post-polio syndrome patients as a young physical therapist in the 1980’s. While there is no true cure for the progression of symptoms, studies showed that non-fatiguing exercise could improve muscle strength and reduce tiredness; the key for us as therapists was to find a delicate balance of not too much exercise, but not too little.

Now here we are in the midst of a coronavirus pandemic, with far more cases than we saw with polio. Over 30 million people have been infected in the USA as of March 2021. Early studies report that 20-27% of those who have technically recovered from even mild cases of COVID-19 continue to show symptoms over 2 months later.

This group has been dubbed “COVID-19 long haulers,” with their presentation being called “long COVID syndrome,” “post-acute sequelae of SARS-CoV-2 infection,” or “Post-COVID-19 syndrome.” Their symptoms include various combinations of fatigue, weakness, low endurance, brain fog, headache, numbness and tingling, distorted sense of smell, altered taste, dizziness, blurred vision, chest pain, cough, shortness of breath, anxiety, variation of heart rate and blood pressure, abdominal pain, nausea, low back and other joint pain. It has become obvious that COVID-19 is a multi-organ disease with nervous system involvement that has a very broad reach. For some these symptoms are a bother; for others they are debilitating.

As the number of “long haulers” begins to increase, health care professionals are at a crucial point to find valid ways to help. Ai Chi is a credible intervention for many of the symptoms that COVID-19 long-haulers experience, as it provides core muscle strengthening, increases joint mobility, improves focus, brings relaxation and reduces stress, enhances breathing, decreases heart rate and blood pressure and relieves back and joint pain. Importantly however, we need evidence-based research showing its effectiveness in Post-COVID-19 syndrome. A good place for practitioners to start is with case studies employing good research practices, including informed consent, controlled parameters and valid test measures. And those who have the resources can undertake larger scale studies with control groups based on the initial findings suggested by case studies. As a reviewer for the APTA’s Journal of Aquatic Physical Therapy, I see this as an important research area today that can have a big impact on the lives of many. I am looking forward to seeing your research!

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